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SAN, AQ"OUNTY ENVIRONMENTAL HEALT*ARTMENT <br /> ' SERVICE REQUEST <br /> Type of Business or Property yt}/ FACILITY ID# SERVICE REQUEST# <br /> O NER/OPST 0&7— <br /> lC/O? �v CHECK if BILLING ADDRESS <br /> -IMM <br /> '3/F��r <br /> SITE ADDRESS � / e �StreetNumber Dtion Street Nae 1771�� <br /> hy Zip Code <br /> HO E/O�cy/]MAA. X43 ADDRESS ((ifMoe <br /> tfrom Site Address) <br /> ml Street Number _ Street Name <br /> C � STATE ZIP <br /> �J <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 7) ) _ 03 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R UESTQR <br /> ,/`p'',/`J'', CHECK if BILLING ADDRESS <br /> BUSINESS NAME PIIPN E#)� <br /> Exi. <br /> H E r !-ING ADDREESJI FAX# <br /> f i� 1 (3/3 ) 33 - S <br /> CIT/!-� < J STATE ZIP <br /> n <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned propert% or business owner, operator or authorized agent of same. <br /> ackno«ledge that all site and/or prqject specific ENVIRONDIENTA L HEALTH DEPAaRTNIENT hourlc charges associated with this project <br /> Of activit` will be pilled to me or m,% business as identified on t s form. <br /> I also certify that I have prepared this app is tion and that the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FEDERAL Ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/Bus;INE%ORNERO0-- - ATOR/N I I N OTHER-WrHORIZED AGENT <br /> If_4F,z'LIC4.\"T is n t rheBiLLL\-c R4RT1-,procfojarttltoriZatior:to sign is regnirect j Tiff <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable.L the owner or operator of tlk[ted at the <br /> above site address, here[)-,- authorize the release of ane and all results.. geotechnical data and/or en\ m <br /> essent <br /> information to the SAN JO AQUIN Cc:ItrNTY EN\IR(./miENTA L HEALTH DEPAaRTAIENT as soon as it is available lie s nue time it is <br /> provided to me or m-%-representative. <br /> DEC - 9 2004 <br /> TYPE OF SERVICE REQUESTED: v's-r <br /> COMMENTS: �!1� S `)Qi` <br /> U�11�1 �?f15 • J /LYZ�C %/1V M ���J `�D �✓��5��//I� �1�L52 T ���yi��- <br /> 02) <br /> ACC D BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: Fkat/% DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 t�f PIE: ngv <br /> Fee Amount: C Amount Paid/ _ Payment//Date <br /> Payment Type Invoice# Check# g D Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11!17!2003 <br /> P <br />